Day-case Basis Research Articles

BN SO09 - Same day discharge after laparoscopic cholecystectomy: Getting It Right First Time (GIRFT)

Abstract Background A key component of elective recovery strategy is to increase day-case provision. GIRFT standards recommend that at least 85% of elective laparoscopic cholecystectomies (LC) should day-cases; most hospitals struggle to achieve this and we aimed to identify barriers to same day discharge after LC. Method Consecutive patients who had LC between December 2022 and March 2023 were identified. Electronic patient records were interrogated to analyse outcomes, length of stay and in-patient treatment. Results 138 patients included, 93 (67%) had elective surgery: ConditionNumber of patients (%)Proportion of elective:acuteBiliary Colic66 (47.5%)60:6 (91.0%:9.0%)Pancreatitis17 (12.2%)4:13 (23.5%:76.5%)Cholecystitis40 (30.0%)19:21 (47.5%:52.5%)CBD stones11 (7.9%)8:3 (72.7%:27.3%)Gallbladder polyp2 (1.4%)2:0 (100%:0%)Cholecystitis and CBD stones2 (1.4%)2:0 (100%:0%) 66 elective patients (70%) were discharged on the same day. Common reasons for staying overnight were late finish (11, 15%), drain or antibiotics (10, 14%) and anaesthetic reasons (10, 14%). Of admitted patients, 15 (21%) did not have any post-operative investigations and 21 (30%) had no in-patient treatment. Conclusion Most patients were managed on a day-case basis, though not to national GIRFT standards. Of admitted patients, 30% did not need in-patient treatment; these patients could have safely been sent home and had they been, the unit would have met national standards. These results highlight the potential for an extended stay area or a post-operative next-day treatment area to increase day-case activity.

Dexmedetomidine versus Dexamethasone as Adjuvant to Bupivacaine in Fascia Iliaca Block in Knee Arthroscopy for Postoperative Pain

Abstract Background Knee arthroscopy is one of the most frequently performed interventions in orthopedic surgery that is commonly performed on a day-case basis. It allows the diagnosis and management of a wide range of knee problems without making a large incision, thus decreasing soft tissue trauma. However, postoperative pain is a common upsetting symptom following arthroscopic knee surgery that if inadequately treated, leads to prolonged duration of the functional rehabilitation of the knee, recovery time and the length of hospital stay thus a significant increase in the medical care costs. Aim of the Work To compare the adjuvant effect of adding dexmedetomidine and/or dexamethasone to bupivacaine while using facsia iliaca block for knee arthroscopy and their efficacy in achieving postoperative analgesia. Patients and Methods The type of study was a prospective double – blinded randomized controlled Trial conducted in Ain Shams University hospitals, Cairo, Egypt at 6 months. Patients aged 20 to 60 years scheduled for elective knee arthroscopy under spinal anesthesia were included to receive FICB. Results In general, there was no significant difference between the three study groups regarding general patient characteristics as well as operative time. That ensured proper randomization conducted between our study groups. Additionally, that should nullify any bias that may have skewed the results in favor of one group rather than another one. There was statistically significant difference between groups according to heart rate from after 2hrs to after 24hrs this was also observed while measuring the systolic blood pressure and diastolic blood pressure but there was no significant difference between group B and C. Conclusion Our study shows that adding Dexmedetomidine and/or Dexamethasone (8mg) to Bupivacaine for FICB significantly prolonged the duration of block and decreased the requirement of rescue analgesics as compared to patients who received Bupivacaine alone. FICB is relatively easy and safe to perform. In our study we did not encounter any complication while doing the procedures and also by adding dexmedetomidine and/or dexamethasone (8mg).

Home initiation of apomorphine infusion: lessons from the COVID-19 pandemic and implications for current clinical practice

Starting Parkinson’s disease (PD) patients on subcutaneous apomorphine (APO) infusion is generally undertaken on a hospital day-case basis. During the COVID-19 pandemic, day-case facilities were unavailable. To avoid delays in treatment, a new procedure was developed for initiation of APO therapy in the patient’s home. A home initiation protocol was developed and followed for each patient in this analysis. The hospital team worked in collaboration with APO nurses provided by the manufacturer of APO therapies to implement initiation and undertake follow-up. In this analysis, 27 PD patients were initiated onto APO infusion and 21 (77.8%) achieved a therapeutic response. Home initiation of APO infusion can be undertaken successfully and has benefits for both patients and healthcare teams. This protocol will now continue as a standard of care at our centre.

Comparison of analgesic efficacy of topical tramadol versus topical lidocaine in the control of postoperative pain in children after tonsillectomy: A randomized double-blinded clinical trial

Background and aim Tonsillectomy is considered one of the most frequent minor surgeries conducted on a day-case basis on children, and usually associate with pain and sore throat. This study aimed to compare the effect peritonsillor tramadol and lidocaine in pain alleviation after tonsillectomy in pediatrics. Patients and methods This prospective, randomized, double blind, controlled clinical study included 80 children, aged 4–15 years. They were distributed into two groups; Group T (n=40) patients received swabs soaked with tramadol 5% diluted with saline 0.9% up to 10 ml; group L (n=40) patients received swabs soaked with ledocaine 2% 2 mg/kg diluted with saline 0.9% up to 10 ml. Post operative pain scores, bleeding, nausea, vomiting, sore throat, otalgia, fever, halitosis, and trismus were recorded. Results Pain score was significantly reduced in the lidocaine arm within two hours after surgery, compared to the tramadol arm (P<0.05). The mean modified VAS score at day 7 was significantly reduced in the tramadol arm, compared to lidocaine arm (1.21 Vs 2.42, P<0.05). No significant difference between the two arms was reported, in terms of postoperative nausea and vomiting, halitosis, fever and otalgia. More serious complications like post-tonsillectomy bleeding or trismus were not reported in either groups Conclusion Topical 5% tramadole and lidocaine has a significant value in post tonsillectomy analgesic effect. Lidocaine had rapid onset at 15 min and duration prolonged up to 2 hours. Tramadol had delayed onset and prolonged duration from 4 hr up to 7 days.

Role of routine chest xrays and device checks in detecting peri-procedural complications associated with cardiac device implantation: a UK tertiary centre experience

Abstract Introduction Complications associated with Cardiac implantable electronic devices (CIEDs) are not uncommon, most of which occur in the perioperative phase. Until recently, guidance on implemented measures for early detection of peri-operative complications were lacking. The ESC guidelines on pacing recommend routine follow up of all newly implanted devices within 72 hours of implant. While the recently published EHRA expert consensus and practical guide on CIEDs recommend that a chest x-ray should be performed within 24 hours in all patients to rule out pneumothorax and document lead positions. Purpose At our tertiary centre for CIEDs, it is routine practice to perform CIEDs implantations on a day-case basis, targeting same day discharge for uncomplicated procedures. CXRs are performed 4 hours after the implant, and CIEDs are fully checked twice, once “on table” at the end of the procedure, and again after mobilisation and prior to discharge. In our analysis, we aimed to identify the yield of complications that could be detected early-on using these routine measures in all our implant procedures. Methods We performed a retrospective analysis of consecutive CIED implants performed between January and December 2019. The following information were collected; types and indications for device therapy, device checks reports, CXR reports, and clinical notes for documented symptoms or signs suggestive of peri-procedural complications. Results A total of 578 patients (Age 74±16 years, 68% male) were included in our analysis, for demographics see table. All patients had routine CXRs and 2 device checks. There were 16 (2.8%) peri-procedural complications associated with our device implants, 7 (1.2%) pneumothoraxes, 6 (1%) pericardial effusions, and 3 (0.5%) lead displacements. In 4 out of the 7 peri-procedural pneumothoraxes, the operator reported difficulty gaining access. 2 patients with pneumothorax reported chest pain, 1 patient reported shortness of breath and 1 had low O2 saturations. There were 2 asymptomatic cases of pneumothorax after reportedly straightforward procedures and were only detected on the routine CXRs, one of them required chest drain insertion and the other treated conservatively. 2 out of the 3 lead displacements were detected on both CXRs and pre-discharge pacing checks and didn't require intervention, while 1 case of lead displacement occurred after the pacing checks and CXRs were reported to be satisfactory, further pacing checks triggered by patient's symptoms and bradycardia on the monitor revealed lead displacement requiring intervention prior to discharge. Conclusion Routine post CIED implantation CXRs can detect early – otherwise clinically silent-periprocedural complications and appropriately remains a requirement for all CIED implants. While repeat post mobilisation device checks has low yield of detection of complications and can be reasonably abandoned provided that initial “on-table” checks are satisfactory. Funding Acknowledgement Type of funding sources: None.

488 TULA for Bladder Tumours in a University Teaching Hospital: Outcomes Over a 2-Year Period

Abstract Aim TULA (Transurethral laser ablation) of bladder tumours is a relatively non-invasive procedure that is carried out on a day-case basis under local anaesthesia, providing an attractive option for treating recurrent non-muscle invasive bladder cancer (NMIBC). However, data describing efficacy rates are limited. Method We carried out a retrospective audit of all TULA procedures carried out for bladder lesions between January 2018 and December 2019. Patients were identified using clinical coding and data collected using electronic case note data. Analysis was performed using Microsoft Excel. Results 48 patients were identified, 75% were male and the average age was 77. Performance status (PS) was formally documented in 6 patients, with a median of 2.5. A total of 77 TULA procedures were identified. 7 patients had TULA as primary treatment, all but one of these patients had significant co-morbidities. Biopsies were taken in 83% of procedures. Recurrence rate at 3 months was 29% (n=14). 18% (n=8) of patients went on to have repeat TULA and the remainder went on to have TURBT or biopsy and cystodiathermy. Of those patients with recurrence, 18% had disease progression. 1 patient required catheterisation and irrigation overnight, all other patients were discharged the same day. No patients required re-admission. Conclusions TULA is a safe, well tolerated procedure to treat low-grade, recurrent bladder tumours. It can also be used as a palliative procedure for high-grade lesions in patients with multiple co-morbidities. Future work includes collection of objective data on tolerance in the form of VAS pain scoring.

Blood cancer care in a resource limited setting during the Covid-19 outbreak; a single center experience from Sri Lanka.

BackgroundThe Covid-19 pandemic has caused significant morbidity and mortality among patients with cancer. Most countries employed measures to prevent spread of Covid-19 infection which include shielding, quarantine, lockdown, travel restrictions, physical distancing and the use of personal protective equipment. This study was carried out to assess the change in patient attendance and the efficacy of newly implemented strategies to mitigate the impact of Covid-19 on services at the Lanka Hospital Blood Cancer Centre (LHBCC) in Colombo, Sri Lanka.MethodologyTelephone consultation, infection control, personal protective measures and emergency admission policy were implemented with the aim of having a Covid-19 free ward and to prevent cross-infections. This descriptive cross-sectional study was conducted with 1399 patient episodes (in-patient care or day-case review). We analysed patients treated as in-patient as well as day-case basis between 01st April 2020 and 31st December 2020.ResultsThere were 977 day-case based episodes and 422 in-patient based episodes. There was a 14% drop in episode numbers compared to same period in 2019. There was no cross infection and no patients with Covid-19 related symptoms or positive test results entered the LHBCC during the study period.ConclusionServices in blood cancer care were maintained to prevent late stage presentation and adverse outcome. Measures implemented to prevent Covid-19 were effective to allow continuation of treatment. This study highlights the importance of implementing strict protocols, clinical screening, use of appropriate personal protective equipment in delivering blood cancer care during the Covid-19 pandemic. This is the only documented study relating to outcome and successful applicability of measures to prevent spread of Covid-19 infection and maintaining services among blood cancer patients in Sri Lanka.

Therapeutic Procedures for Malignant Ascites in a Palliative Care Outpatient Clinic.

The optimal treatment of malignant ascites (MA) and feasibility of the management with free drainage remain unclear. To study the success of drainage, complications, and survival after paracentesis or insertion of an indwelling tunneled catheter (TC) for the MA performed on a day-case basis. We evaluated 118 paracenteses and 48 insertions of TCs performed in 104 patients with MA at the Palliative Care Outpatient Unit of Tampere University Hospital. Drainage of ascites fluid (median 3700 mL; range 300-13,200 mL) was successful in all cases. The complication rates were 7% and 25% for paracenteses and TCs, respectively. Most of the complications were minor. Repeated procedures were needed in 64% and 10% of the paracenteses and insertions of TCs, respectively, (p < 0.001). Median survival after the first procedure was 40 days (interquartile range, IQR: 17-115). Patients with pancreatic cancer had shorter median survival (19 days; IQR: 9-35) compared with other patients (47 days; IQR: 23-143) (age-adjusted HR 2.73; 95% CI: 1.65-4.52), whereas patients receiving chemotherapy had longer median survival (112 days; IQR: 43-205) compared with patients without chemotherapy (25 days; IQR: 14-52) (age-adjusted HR 2.48; 95% CI: 1.58-3.89). The volume of removed ascites fluid was not associated with survival. Free drainage of MA seems feasible in an outpatient clinic. Early insertion of TC should be considered to avoid repeated paracenteses. However, in patients with pancreatic cancer, paracentesis might be an accepted alternative due to their short life expectancy.

GreenLight XPS™ Vaporisation of the Prostate Has Proven Cost-Effective

Benign prostatic hyperplasia (BPH) is common in men aged &gt;60 years, affecting urinary and bladder function. Due to the progressive nature of the disease, many men initially treated with conservative therapies require surgical intervention for symptom relief. Less invasive techniques, such as transurethral microwave therapy, needle ablation, transurethral resection of the prostate (TURP), and laser treatment, have been developed with TURP being the standard of care for BPH in Europe in prostates &lt;80 mL (volume). For an increasingly ageing male population often receiving anticoagulants for cardiovascular comorbidities, TURP may not be suitable due to high risk of bleeding, requirement for bladder washouts, and blood transfusions. Owing to these requirements and potential complications associated with surgery, TURP is performed as inpatient surgery requiring a 2 to 4-day hospital stay. In the GOLIATH study, the 180 W GreenLight XPS™ laser system demonstrated comparable efficacy with TURP at 6 and 12 months, while maintaining low rates of adverse events, retreatments, or postoperative interventions in low-risk patients. Recovery parameters significantly favoured GreenLight XPS over TURP, thus greatly supporting GreenLight XPS use for BPH treatment during short-term stay. There is a requirement for healthcare services to minimise costs. Estimated on a day-case basis, GreenLight XPS was significantly more cost-effective than TURP with a 25% reduction in procedural cost, lower indirect costs, and lower financial burden based on efficacy and adverse-event outcomes. Therefore, GreenLight XPS represents an appropriate treatment option for day-case surgery and a treatment that can be tailored to individual patient needs.

Outcomes of endoscopic ethmoidectomy performed on a day-case basis: a prospective bi-centric study.

Evaluation of endoscopic ethmoidectomy performed as a day-case in terms of security, quality, and satisfaction of the patient. This prospective observatory bi-centric study over 1year included 74 patients undergoing an ethmoidectomy respecting the eligibility criteria of ambulatory care. We recorded patients' demographic data, operative details, satisfaction, postoperative course, and follow-up results. Nasal symptoms were evaluated by SNOT-22 on preoperative appointment and postoperatively at D30. No non-absorbable nasal packing was used, eventually in the case of preoperative-bleeding absorbable gelatine packing. The postoperative follow-up took place at D1 by phone call and at D10 and D30 to assess complications, Visual Analogue Scale, and state of ethmoidal corridors by endoscopic exam. Patients benefited of bilateral ethmoidectomy in 82.4% cases associated with septoplasty in 42%. The majority (95%) was discharged on the same day. Only one patient had bleeding at D0 and was kept in standard hospitalization, such as three other patients for medical or organizational reasons not related to surgery. At D1, 23% described postoperative light bleeding but needed no revisit and pain was estimated at 1.3 (VAS). No readmission was observed, and no major complication was noted. SNOT-22 decreased successfully by 56%, statistically related to postoperative treatment of corticosteroids and in the case of Samter triad. 97% of patients were satisfied of the ambulatory care. These results suggest that within an experienced and dedicated day-case medical and paramedical team, ethmoidectomy can be safely performed on a day-case basis with high quality of taking care and satisfaction of patients.

Day-Case Treatment of Peripheral Arterial Disease: Results from a Multi-Center European Study.

The purpose of the study was to investigate safety and feasibility of day-case endovascular procedures for the management of peripheral arterial disease. This was a multi-center, retrospective study including all patients treated over a 30-month period with endovascular angioplasty or stenting for intermittent claudication (IC) or critical limb ischemia (CLI) on a day-case basis, in Interventional Radiology (IR) departments of three European tertiary hospitals. Exclusion criteria were not related to the type of lesion and included unavailability of an adult able to take care of patient overnight; high bleeding risk and ASA score ≥4. Primary efficacy outcome was the rate of procedures performed on an outpatient basis requiring no further hospitalization and primary safety outcome was freedom from 30-day major complications' rate. The study included 652 patients (male 75%; mean age 68±10years; range: 27-93), 24.6% treated for CLI. In 53.3% of the cases a 6Fr sheath was used. Technical success was 97.1%. Haemostasis was obtained by manual compression in 52.4% of the accesses. The primary efficacy outcome occurred in 95.4% (622/652 patients) and primary safety outcome in 98.6% (643/652 patients). Major complications included five (0.7%) retroperitoneal hematomas requiring transfusion; one (0.1%) common femoral artery pseudoaneurysm successfully treated with US-guided thrombin injection, two cases of intra-procedural distal embolization treated with catheter-directed local thrombolysis and one on-table cardiac arrest necessitating >24h recovery. No major complication was noted after same-day discharge. Day-case endovascular procedures for the treatment of IC or CLI can be safely and efficiently performed in experienced IR departments of large tertiary hospitals.

Pediatric myringoplasty: Prognostic factors in surgical outcome and hearing threshold recovery

Conclusions: This study shows as decisive factors the history of tympanostomy tube insertion and surgical approach. The closure of the perforation observed at the 6th post-operative month is almost definitive, without finding significant differences ahead. The myringoplasty can be performed simultaneously in bilateral perforations and in a day-case basis with same success rates. Astatistically significant audiometric improvement area is described, after myringoplasty, undescribed previously in literature. Objectives: The aim of this study was to evaluate prognostic factors in surgical outcome and hearing threshold after myringoplasty, in pediatric age. Methods: A 10-year retrospective review of 142 myringoplasties performed by a single surgeon of the Pediatric ENT Department of 12 de Octubre University Hospital. Multiple prognostic factors were investigated, such as those related to perforation and surgery, contralateral ear status, and pre- and post-operative hearing threshold. Results: The overall rate of closure of the perforation was 74.64%. The re-perforation rate was directly proportional to the number of tympanostomy tube insertion (OR = 1.64). Other determining factors were the surgical approach, the graft position and side. There was a post-operative significant improvement (p < 0.001) insuring that the more affected frequencies, low (125–500 Hz) and high frequencies (4000–8000 Hz), were the more improved after the procedure.

PTU-003 Flexible endoscopic diverticulotomy is a safe and viable treatment for zenker’s diverticulum: a video case series

Introduction Zenker’s diverticulum is a sac-like outpouching of the mucosa and submucosa through an area of muscular weakness between the thyropharyngeus and cricopharyngeus muscles. Traditional treatments have been surgical with open or intraluminal approaches to cricopharyngeal myotomy where the overall complication rate is 9.6%. An alternative approach is to use a flexible endoscope to perform a diverticulotomy. We present a video series to illustrate the principles of flexible endoscopic diverticulotomy. Method We reviewed prospectively collected data of patients with Zenker’s diverticulum referred to our department for endotherapy between January 2014 and January 2015. All patients had Zenker’s diverticulum confirmed on barium swallow. Every procedure was carried out under general anaesthesia by a single endoscopist (PB). A guide wire is inserted into the stomach under direct vision, over which a double-lipped overtube (ZD overtube, ZDO-22–30; Cook Endoscopy, Winston-Salem, North Carolina) is threaded. Under direct vision, the overtube is advanced until the long flap is positioned in the oesophageal lumen and the short flap is in the diverticulum. The septum is clearly visualised and stabilised between the two flaps. The septal mucosa is cut in the middle using a needle knife or diathermy scissors. The mucosal incision is extended until the cricopharyngeal muscle fibres are completely incised. Following this, the cut is extended to approximately 1 cm from the base. Prophylactic endoclips are placed to prevent perforation or bleeding. Patients resume a liquid diet 12 h post procedure. Results A total of 5 patients underwent flexible endoscopic diverticulotomy [female 3, median age 76 years (range 69–84 years)]. 2 patients had previous failed surgical interventions. The mean size of diverticulae was 48 mm (range 30–70 mm) and the mean duration of each procedure was 33 min (range 30–40 mins). 1 patient required an overnight stay as he lived outside our catchment area. There were no procedure related complications or mortality. All patients were able to drink within 12 h and start on a soft diet within 48 h post procedure. Prior to the diverticulotomy, 80% of patients experienced dysphagia with every meal and 60% suffered with regurgitation several times a week. All patients were asymptomatic at follow up at 3. Where 12-month data is available, all patients (3/5) remain asymptomatic. Conclusion In expert hands, flexible endoscopic diverticulotomy is a novel, and safe treatment for Zenker’s diverticulum. It obviates the need for invasive surgery and a majority of patients can be treated on a day-case basis. Initial results are encouraging with no reported complications and excellent short-term success rates. Disclosure of interest None Declared.

English

INTRODUCTION: Shoulder arthroscopy is a common orthopedics procedure performed on day-case basis. Adequate pain relief reduces surgical stress response, patient's morbidity and improves postoperative recovery and rehabilitation. Various drugs have been tried intra-articularly to provide postoperative analgesia. PURPOSE: We studied analgesic effect of dexamethasone 16mg (4ml) with ropivacaine and compared it with ropivacaine intra-articularly in shoulder arthroscopic procedures in search of the ideal analgesic combination. METHODS: A Prospective Multicenter Double Blind study on 60 patients undergoing arthroscopic shoulder surgery from July'13- April'14. Patients were assigned into 3 groups randomly - Group I (20 ml normal saline),Group II (20 ml 0.2% ropivacaine) and Group III (16 ml 0.2% of ropivacaine & dexamethasone- 4 ml containing 16 mg. VARIABLES ASSESSED: Analgesic effect (VAS Score), time to first postoperative analgesic request, Analgesic used during first 24 hours. RESULTS: Group III had significant low pain scores for 1 st 20 hours as compared to Group II and Group I. Time to first analgesic requirement was longest in Group III (1356.2±193.10mins) (p<0.01). Intensity of pain &Total analgesic requirement was significantly less in Group III (38.2±27.83 mg)(p<0.01) in comparison to Group II and I. No significant side-effects were noted. CONCLUSION: A16 mg (4ml) dosage of Dexamethasone is safe, cost effective and free from relative side effects, has a better patient compliance in terms of post-operative pain, need for analgesia and should be used routinely in arthroscopic shoulder surgeries. Helps in the recovery of patients to the pre-operative level.

The effect of intra-articular Tenoxicam on knee effusion after arthroscopy.

NSAIDs and analgesic drugs are used intra-articularly after knee arthroscopy for pain relief. However, synovial effusion is still a common cause of delayed physical therapy. The aim of this study was to demonstrate the beneficial effect of intra-articular injection of Tenoxicam on knee effusion after arthroscopy. This was a prospective non-randomized study on 134 patients with a mean age of 36.7 years. Knee arthroscopy on a day-case basis was performed; normal saline was used for irrigation. At the end of the procedure, fluid was aspirated from the knee joint and 20 ml of Tenoxicam diluted with 20 ml of 0.9% normal saline was injected into the knee five minutes before deflation of limb tourniquet. The same surgeon performed clinical examination for knee effusion 14 days postoperatively. Encountered pathologies included meniscal injury, degenerative arthropathy, synovial plica and ACL rupture. Knee effusion developed in 15.7% of the patients, particularly in those with degenerative arthropathy (p = 0.006) and meniscal lesions (p = 0.06). Intra-articular Tenoxicam is a simple method for the prevention of postoperative knee effusion. Degenerative arthropathy and meniscal lesions are major risk factors for post arthroscopy knee effusion.

Fluoroscopic-guided supra-scapular nerve block in the management of shoulder pain in a Nigerian Teaching Hospital: Report of five cases.

Shoulder pain complaints are common in our environment. The disorder can occur among the young active age group or in the older patients as a result of degenerative changes with its attendant limitations of the function of the affected upper limb, hindrance of the performance of activities of daily living, and reduced quality of life. The traditional oral analgesics, physiotherapy, and intra-articular corticosteroid injections are seldom ineffective at providing the desired pain relief and functional improvement at the shoulder joint. We investigated the role of fluoroscopic-guided supra-scapular nerve blocks (SSNBs) in patients with shoulder pain who failed to respond to the routine conservative management. With the patient lying prone and the C-arm fluoroscope placed in anterior-posterior position, the scapula notch was visualized and a 22G spinal needle was directed toward the nerve. The mixture of local anesthetic agent and steroid was injected as close to the nerve as possible after negative aspiration. Fluoroscopic-guided SSNB can produce substantial pain relief and improved range of movement in patients with painful shoulders. The procedure is safe, well tolerated, and can be done on a day-case basis.

Day-case monopolar and bipolar transurethral resection of the prostate

Objective: The objective of this article is to investigate the safety and efficacy of both monopolar and bipolar transurethral resection of the prostate (TURP) performed on a day-case basis. Materials and methods: Data were collected prospectively for two cohorts of consecutive patients undergoing a day-case monopolar TURP (mTURP) by surgeon 1 in centre 1 (Group M) and a day case bipolar TURP (bTURP) by surgeon 2 in centre 2 (Group B). All were scheduled to be discharged on the day of surgery, with an indwelling catheter to be removed on an outpatient basis. Results: Fifty men underwent a day-case mTURP (Group M) and 27 men underwent a day-case bTURP (Group B) in centre 1 and 2, respectively. Patient age ( p = 0.71) and resection weight ( p = 0.35) were comparable between the two groups. No statistically significant difference in the number of admissions ( p = 1.00) or re-admissions ( p = 0.55) between the two groups was observed, with an identical day case discharge rate of 92%. Conclusions: Day-case TURP can be provided safely and effectively to patients regardless of the diathermy method employed, with successful discharge rates and low risk of admission or re-admission.

Home recovery following day surgery: a patient perspective.

To investigate aspects of care potentially most influencing home recovery following day surgery. Elective surgery undertaken on a day-case basis is expanding. Many medical aspects of recovery have been investigated although less is known about the psychosocial view of postdischarge recovery. Greater insight into such issues is required for the development of a more coordinated nurse-led approach. Cross-sectional questionnaire. As part of a larger study, questionnaires were distributed to 2401 adult patients on the day of operation (September 2010-October 2011) to examine patients' experiences of psychosocial recovery. Participants were requested to complete and return the questionnaire by mail one week after surgery with 684 returned. Eighty-five per cent were fully prepared for all events during home recovery. Satisfaction with pre- and postoperative surgical information was high although less so anaesthetic information. Using factor analysis, preoperative information, pain management, postdischarge information, anxiety management, postoperative nausea and vomiting, help and rest once home were central features. Multiple regression analysis demonstrated pre- and postoperative information provision to have a statistically significant positive association with patients' being 'fully prepared for all events during home recover'. Unsatisfactory pain management, increased anxiety and reduced help once home had a statistically significant negative association with patients' being 'fully prepared for all events during home recovery'. Focusing on the delivery of surgical and anaesthetic information, managing pain and anxiety and ensuring support once home may help to enhance recovery. A more comprehensive plan embracing such aspects could help enhance the day surgery patients' experience. Increased satisfaction and surgical/anaesthetic information are central to the continued success of minimal-stay surgery. A broader hospital/home strategy is required as too frequently nursing care can become fragmented between the preoperative outpatient visit, preassessment, day of surgery and postoperative outpatient visit.

The Continuous Evolution of the Greenlight Laser; the XPS Generator and the MoXy Laser Fiber, Expanding the Indications for Photoselective Vaporization of the Prostate

To report our early experience with new GreenLight XPS™ generator using the new MoXy laser fiber, examining its efficacy and safety and also its ability to effectively treat the larger prostate gland. From July 2010 until August 2012, 131 patients, with an average age of 72.6 years (range 49-92), were treated using the XPS/MoXy system in a single U.K. center on a day-case basis. Data were prospectively collected. Evaluation of outcome was assessed at 3 months postoperatively comparing both subjective (international prostate symptom score [IPSS]) and objective (Q-max, postvoiding residual [PVR] and prostate volume) parameters to the preoperative data and classified into three groups according to the preoperative prostate size (<40 cc, 40-80 cc, and >80 cc). More than one quarter of patients had a prostate volume >80 cc. Overall significant improvement in IPSS (mean reduction by 9.9) and Q-max (mean increase 10.26 mL/sec) are observed and were similar across the three groups. Average volume reduction was (51.2%, 49.8%, & 48.1%) for the three groups, respectively. No significant intraoperative or early postoperative complications were reported. Early data confirm that in treating men with symptomatic benign prostate disease, the Greenlight XPS generator and MoXy laser fiber are able to achieve challenging results in terms of clinical outcome and prostate volume reduction irrespective of baseline prostate volume.

Propranolol therapy for cutaneous infantile haemangiomas initiated safely as a day-case procedure

Propranolol is emerging as the treatment of choice for high-risk infantile haemangiomas. Current protocols recommend overnight admission for initiation of propranolol as well as baseline investigations including electrocardiography (ECG) and echocardiography (ECHO). Our study examined the safety profile of propranolol for the treatment of infantile haemangiomas using a simplified day-case initiation protocol. We evaluated 20 consecutive patients commencing propranolol as a day case for the treatment of an infantile haemangioma over an 18-month period. Investigations were carried out according to our local protocol. Cardiac investigations were not routinely performed. Patients were observed for 2h following administration of the first dose of propranolol (0.5mg/kg orally). If no adverse effects were observed, patients were discharged on a daily dose of propranolol of 1mg/kg, increased to 2mg/kg on day 4. Patients were reviewed on the day ward on day 8. All haemangiomas requiring treatment were small to moderate in size (median maximum diameter 2.35cm). Except for capillary blood glucose measurement, no patient required venepuncture for additional blood investigations. As all patients had a normal clinical examination, none required ECHO. An ECG was performed on just one patient. No adverse reactions were observed following administration of propranolol. All patients were discharged home on the same day. No serious adverse events were reported at follow-up. We demonstrate that with targeted cardiac screening, propranolol can be safely initiated on a day-case basis for the treatment of small- to moderate-sized infantile haemangiomas.